Erotomania

Erotomania also known as De Clerambault’s syndrome, is a rare delusional disorder in which an individual has a delusional belief that another person, usually of higher status, is in love with him/her ¹. This form of delusion is more common in females and often results in stalking ². This fixation on being loved by the other person is considered delusional because it’s not based in reality. In most cases, the person hasn’t even met the person they’re fixated on. Some people with De Clerambault’s syndrome may believe that a stranger they’ve just met is in love with them. A person with erotomania may believe that the other person is attempting to send them secret messages. They can believe this is happening through the news or thoughts also called telepathy.

While rare, erotomania does result in both nonfatal violence and homicide against the love interest or against others who may be perceived as potential rivals or who the stalker believes may have some other irrationally derived role to play in bringing the stalker and their target together. Little is known about the background, classification, treatment, or outcome of individuals with erotomania ³. Previous case reports have shown that social media networks may play a role in worsening the delusional beliefs ⁴.

Erotomania can be associated with other mental health conditions that involve delusions or manic behaviors.

Erotomania is a relatively rare condition, and while the incidence is unknown, the lifetime prevalence of delusional disorder is 0.2% ⁵. Consequently, many psychiatrists do not encounter or may fail to recognize erotomania in their clinical practice. Although many theories exist for the cause of delusional disorder, recent postulations have suggested that social media networks may play a role in enmeshing technology into the delusional systems of those predisposed to psychosis ⁶. Social media networks are now ubiquitous aspects of modern society, and this implication cannot be overlooked. Although social media has been linked to schizophrenia exacerbations, this appears to be the first identified case of exacerbated delusional disorder ⁶.

Erotomanic type

De Clerambault ⁷ described two forms of erotomania syndrome, pure or primary erotomania, and secondary of recurrent erotomania. In the pure erotomania, the delusion exists alone. There are never any hallucinations nor global or absurd megalomaniac conceptions. No “insanity” is present in this form, yet the onset is sudden. The illness is clearly defined, the course chronic. In the secondary erotomania, the disorder is associated with other psychoses-most commonly, paranoid schizophrenia. It is often seen with a wide range of persecutory themes, ideas of grandeur and mysticism. The onset is gradual, the illness is diffuse. There is also the possibility of a future different love object and transference.

Seeman ⁸ divided her patients into two groups: the fixed and the recurrent erotomania. Patients in the fixed group were more seriously ill. The delusion remained constant and chronic despite treatment. Erotomania appeared to occur in poorly integrated women who were dependent, timid, unpredictable and had few heterosexual experiences. These women seemed to feel inferior to others. Each selected a lover who was viewed as someone who was superior to them from a socioeconomic-cultural vantage point. More often, they were diagnosed as schizophrenic. The delusion appeared to serve as a defense against low self-esteem, sexuality and external aggression.

On the other hand, patients in the recurrent group were less psychiatrically ill. The delusions were recurrent, short-lived and intense. The illness occurred in some who were characterized as healthier, aggressive, impulsive and more sexually active. These women selected lovers who were powerful and prominent. Their delusions served as a defense reaction against homosexual doubts and feelings of competitiveness or resentment and may have been an attempt to incorporate power and self-image.

Erotomania causes

There are numerous theories as to the cause of erotomania or De Clerambault’s syndrome. It is important to mention that erotomania is not uniquely associated with any specific illness. Erotomania or De Clerambault’s syndrome is sometimes found with psychiatric disorders such as bipolar affective disorder ⁹, schizophrenia ¹⁰, senile dementia ¹¹, meningioma, alcoholism ¹² or even orchidectomy ¹³.

One theory involves a neuroscientific basis, in which erotomania is actually a form of schizophrenia with a neurochemical imbalance. In this instance, attempts to restore the balance through dopamine and serotonin blockers are being made. One study ¹⁴ demonstrated an association between the onset of erotomania and the use of high doses of the antidepressant venlafaxine. Although venlafaxine has primary effects on the 5-hydroxytryptamine and norepinephrine uptake, repeated administration was found to also affect the dopamine system ¹⁴. The increase in the responsiveness of postsynaptic dopamine 2/dopamine 3 receptors in the mesolimbic system with high doses of venlafaxine could be responsible for the emergence of a psychotic illness ¹⁵.

Another theory is that of a genetic basis. Here, it is postulated that a person may be genetically predisposed, hence, the disorder appears in successive generations.

Subjects in a study by Kennedy et al. ¹⁶ reported strong family histories of psychiatric disorders, with three having a first-degree relative with a history of a delusional disorder-two of schizophrenia and one of psychotic bipolar affective disorder. One subject in this series has a history of morbid jealousy and erotomania in life and a maternal history of delusional morbid jealousy. Another subject’s mother had a history of morbid jealousy, and one subject’s sister also had a history of erotomanic delusions. Morbid jealousy and erotomania occurring in successive generations have been described and explained psychodynamically as being due to lack of basic trust ¹⁷.

Various psychodynamic formulations have been offered. Enoch et al. ¹⁸ believed that erotomania evolved out of the search for a safe and unattainable eroticized father figure and the need to ward off homosexual impulses. It was Freud’s ¹⁹ belief that erotomania in the male was a variant of paranoia resulting from denial, displacement and projection. Through this, a formula evolves: “I do not love him; [rather] I love her because she loves me.” The sex of the-patient does not seem to influence the structure of the delusions. Hence, for women, using Freud’s formula, this would be transformed into “I do not love her; I love him because he loves me.” Cameron ²⁰ views erotomania as self-love that has been denied and projected onto a man. Raskin and Sullivan ²¹ view erotomania as an adaptive function, warding off depression and loneliness following a loss. Hollender and Callahan ²² suggest that the erotic delusion is the result of an ego deficit shaped by an intrapsychic struggle of feeling unlovable following a narcissistic blow. Feder ²³ views romantic love, behind which lies the drama of an ontogenetic earlier phase of life elaborated in psychosis. He further relates that under conditions of regression, it is an attempt at restoration of the earlier blissful union with the mother figure.

Still another postulation is that environmental, psychological, pharmacological and physiological factors may often trigger a predisposed person into developing erotomania ²⁴. Finally, it has also been postulated that learning through the media (television, radio, books, etc.) has influenced the development of this particular type of delusion. This is the “Cinderella syndrome”, the young girl’s fantasy of Prince Charming.

Erotomania symptoms

Erotomania is a relatively uncommon and misunderstood disorder characterized by the presence of a persistent erotic delusion. Erotomania or De Clerambault’s syndrome components, as summarized by Taylor et al., are ²⁵:

• the presence of a delusion that the individual (usually described as a female) is loved by a specific man;
• the woman has had little or no contact with the man;
• the man is unattainable in some way, because he is already married or because he has no personal interest in her;
• the man is perceived as watching over, protecting or following the woman;
• despite the erotic delusion, the woman remains chaste.

Erotomania main symptom is a person’s false belief that someone is deeply or obsessively in love with them. There’s often no evidence of the other person’s love. The other person may not even be aware of the existence of the person with erotomania.

A person with erotomania might talk about the other person constantly. They may also be obsessed with trying to meet with or communicate with this person so that they can be together.

Erotomania common symptoms include:

• obsessively consuming media related to the other person if they are a celebrity or public figure
• constantly sending letters, emails, or gifts to the other person
• persistently making phone calls to the other person
• being convinced that the other person is trying to secretly communicate through glances, gestures, or coded messages in the news, television shows, movies, or social media
• creating elaborate but false situations in which the other person is pursuing them, stalking them, or trying to get in touch with them
• feeling jealous due to a belief that the other person may be in contact with other “lovers” or may not be faithful
• harassing the other person in public, sometimes to the point of being reprimanded or arrested by law enforcement
• losing interest in activities other than talking about the other person or doing activities related to them.

People with erotomania may bring chaos into the lives of their victims. A grotesque drama often ensues when erotomanic patients act on their delusions, relentlessly bombarding their victims with
telephone calls, letters, gifts and visits. Persistent surveillance and stalking may occur. After repeated professions of love and advances are unrequited, these patients may become dangerous, as resentment and rage are mobilized in response to perceived rejection by the love object. Although actual physical and sexual assaults are uncommon, these patients may inflict enormous psychological and social disruption as a consequence of their merciless harassment and pursuit over a period of many years. Victims may be reduced to living in an unrelieved state of siege ²⁶. Motivation for the stalking behavior has been found to emerge from a desire to forge an intimate relationship with the victim. Purcell et al. ²⁷ found that in their sample, one-quarter of female stalkers manifested erotomanic delusions, with the remainder hopeful that their pursuit would culminate into a relationship.

The nature of the hoped-for intimacy, although usually romantic or sexual, also encompassed such aspirations as establishing a friendship or even a mothering alliance with the victim. In reference to the second case, the patient acted on her delusion by repeatedly contacting the object of her affection. The results of a study by Menzies et al. ²⁸ suggests that the risk and extent of actual physical harm posed by erotomanic subjects may be less than by other categories of stalkers.

Psychotic breaks

Erotomania may happen over a long period of time or only in short episodes known as psychotic breaks. Psychotic breaks are a common symptom of other mental health conditions. They involve an abrupt worsening of delusions or other psychotic features. They may occur in disorders such as schizophrenia, schizoaffective disorder, and bipolar disorder.

Other manic symptoms of bipolar disorder include:

• having an unusual amount of energy
• not being able to sleep
• becoming involved in more activities than are typical for that person
• speaking quickly about many different topics in a short amount of time
• having a lot of thoughts in a short amount of time (known as racing thoughts)
• displaying risky behaviors, such as spending a lot of money at one time or driving recklessly

Erotomania complications

Erotomania can cause someone to show risky or aggressive behavior. In some cases, this behavior can cause the person to be arrested for stalking or harassment. In rare cases, erotomania can result in the death of either person.

Erotomania is often associated with bipolar disorder. It’s also associated with other conditions that include:

• anxiety disorder
• drug or alcohol dependence
• eating disorders, such as bulimia or anorexia
• attention deficit hyperactivity disorder (ADHD)

Erotomania treatment

Treatment for erotomania usually addresses the psychosis or delusional symptoms. This often involves a combination of psychotherapy and medication. Electroconvulsive therapy is another treatment modality noted for temporary effectiveness.

Classic (or typical) antipsychotic medications, such as pimozide, are often used successfully in cases of monodelusional disorder ²⁹. Nontraditional or atypical antipsychotics, such as olanzapine, risperidone, and clozapine, have also been used alongside psychotherapy or counseling. A study by Kelly et al. ³⁰ demonstrated successful treatment of erotomania with risperidone. Risperidone seems to have a more attractive side-effect profile in the dosage used (<6 mg per day) when compared to conventional agents used traditionally in monodelusional disorders.

If erotomania results from an underlying condition, such as bipolar disorder, treatments for this condition may be used. Bipolar disorder is often treated with mood stabilizers, such as lithium (Lithonia) or valproic acid (Depakene).

Erotomania prognosis

Erotomania may only last for a few hours or days, but it can continue for months or years if it’s a result of an underlying mental health condition.

If you notice symptoms of erotomania, seek medical help or see a therapist right away. Getting treated for erotomania before showing risky or aggressive behavior towards another person is crucial in preventing this condition from disrupting both their life and your life.

References

1. Kennedy N, McDonough M, Kelly B, Berrios GE. Erotomania revisited: clinical course and treatment. Compr Psychiatry. 2002;43(1):1–6. doi:10.1053/comp.2002.29856
2. Psychopathology and Criminal Behavior. Applied Crime Analysis A Social Science Approach to Understanding Crime, Criminals, and Victims 2015, Pages 208-252 https://doi.org/10.1016/B978-0-323-29460-7.00011-9
3. Jordan HW, Lockert EW, Johnson-Warren M, et al. Erotomania revisited: thirty-four years later. J Natl Med Assoc. 2006;98(5):787–793. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2569288/pdf/jnma00192-0127.pdf
4. Delusional Disorder, Erotomanic Type, Exacerbated by Social Media Use. Case Reports in Psychiatry Volume 2017, Article ID 8652524, 2 pages https://doi.org/10.1155/2017/8652524
5. J. Perälä, J. Suvisaari, S. I. Saarni et al., “Lifetime prevalence of psychotic and bipolar I disorders in a general population,” Archives of General Psychiatry, vol. 64, no. 1, pp. 19–28, 2007.
6. N. Krishna, B. A. Fischer, M. Miller, K. Register-Brown, K. Patchan, and A. Hackman, “The role of social media networks in psychotic disorders: a case report,” General Hospital Psychiatry, vol. 35, no. 5, pp. 576.e1–576.e2, 2013.
7. De Clerambault GG. Les Psychoses Passionelles, in Oeuvere Psychiatrique: Paris: Presses Universities, de France, 1942;331:337-339,357,408.
8. Seeman, S. Psychotic and Erotic Living-the Difference. Int J Psychother 1 977;6:494-495.
9. Remington G. Case Report of De Clerambault Syndrome, Bipolar Affective Disorder, and Response to Lithium. Am J Psychiatry. 1984;141:1285-1287.
10. Evans Dl. Erotomania. A Variant of Pathological Mourning. Bull Menninger Clinic. 1982;46:507-520.
11. Drevets WC. Erotomania and Senile Dementia of Alzheimer’s Type. Br J Psychiatry. 1987;151:400-402.
12. Doust JW. The Pathology of Love: Some Clinical Variants of De Clerambault’s Syndrome. Soc Sci Med. 1978;12:99-106.
13. Mazeh D, Merimsky 0, Melamed Y, et al. Erotomania Following an Orchiectomy: A Case Report. J Sex Martial Ther. 1997;23:154-1556.
14. Muth EA, Haskins JT, Moyer JA, et al. Antidepressant Biochemical Profile of the Novel Bicyclic Compound Wy-45,030, An Ethyl Cyclohexanol Derivative. Biochem Pharmacol. 1986;35:4493-4497.
15. Adamou M, Hale HS. Erotomania Induced by Venlafaxine: a Case Study. 2003;107(4):314-317.
16. Kennedy N, McDonough Kelly B, Berrios GE. Erotomania Revisited: Clinical Course and Treatment. Comp Psychiatry. 2002;43(1 ):1-6.
17. Berry J, Hayden P. Psychose Passionelle in Successive Generations. Br J Psychiatry. 1980;137:574-575.
18. Enoch MD, Trethowan WH, Barker JC. Some Uncommon Psychiatric Syndromes. Bristol, England: John Wright. 1967;13-24.
19. Freud, S. Psychoanalysis notes on an autobiographical account of a case of paranoia. In the Complete Psychological Works of Sigmund Freud, vol 12. London: The Hogarth Press, 1 958;p63.
20. Cameron, N. Paranoid Conditions and Paranoia. In: Arieti S, ed. American Handbook of Psychiatry, New York, NY: Basic Books, 1959;525-526.
21. Raskin, DE, Sullivan KE. Erotomania. Am J Psychiatry. 1974;131 (9):1033-1035.
22. Hollender MH, Callahan AS. Erotomani or De Clerambault Syndrome. Arch Gen Psychiatry. 1975;32:1574-1576.
23. Feder S. Clerambault in the Ghetto: Pure Erotomania Reconsidered. J Psychoanal Psychother. 1973;2:240-247.
24. Doust JW, Christie H. The Pathology of Love: Some Clinical Variants of DeClarambault’s Syndrome. Soc Sci Med. 1978;12:99-106.
25. Taylor P, Mahendra B, Gunn J. Erotomania in Males. Psycho Med. 1983; 13:645-650.
26. Lloyd-Goldstein R. De Clerambault On-Line: a Survey of Erotomania and Stalking From the Old World to the World Wide Web. In: Meloy JR, ed. The Psychology of Stalking. San Diego: Academic Press, 1998;193-212.
27. Purcell, R, Pathe M, Mullen PE. A Study of Women Who Stalk. Am J Psychiatry. 2001 ;158(12):2056-2060.
28. Menzies R, Fedoroff JP, Green CM, et al. Prediction of Dangerous Behavior in Male Erotomania. BrJ Psychiatry. 1995;1 66(4):529-536.
29. McGuire BE, Akuffo E, Choon GL. Somatic Sexual Hallucinations and Erotomanic Delusions in a Mentally Handicapped Woman. J Intellect Dis Res 1 994;38:79-83.
30. Kelly BD, Kennedy N, Shanley D. Delusion and Desire: Erotomania Revisited. 2000; 102(2):74-75.